Trauma and Its Aftermath

Traumatic events are those experiences that are intrusive, sudden, non-normative and exceeding of an individual’s capacity to meet the defense demands of the encountered event. The essence of trauma is repetition and the reexperience of the event through mental imagery, physical/emotional arousal or numbing and other symptom formation now, in present time. Trauma overwhelms our usual frame of reference of how the world operates — or should operate — and the individual in it.

The range of trauma is as wide as human experience. Examples come from every realm of life and could include:

Personal attack through assault, rape, animal attack, physical/sexual abuse,or emotional abuse.
Global or natural disaster such as war, floods, cultural genocide, earthquake,fire, social dislocation.
Accident or inside injury such as childhood surgery, bike or auto accidents, burns, sporting accidents, chronic disease or health failure, head wounds.
Socially sanctioned trauma such as war, prison, ritual abuse, religious trauma, political terror.
Emotional or developmental trauma such as childhood neglect, severe loss.
Vicarious trauma, that is, being witness to or bystander to others’ traumatization.

We all have coping strategies to help deal with intrusion, attack, physical or emotional overwhelm, but what happens when these strategies fail? When our orienting and defensive responses don’t keep harm or chaos at bay, how does the individual respond, not just to the intrusion itself but the ensuing shock and disruption to self worth, to an emotional life gone chaotic, to having one’s sense of self and place in the world shaken. The events, in the past, come to feel they are being lived in the present. Trauma becomes imprinted on lives in ways that appear to define them.

The lingering impact of trauma, the intrusion of it and its persistence bring people to psychotherapy. They seek relief, resolution and better management of the activation and freezing responses triggered by memories and reenactments of trauma. The reexperiencing shapes us on all levels on which we process information: cognitively, somatically, emotionally, biochemically, neurologically, relationally and, of course, spiritually.

The degree to which trauma symptoms develop or cause impairment hinge on what personal resources an individual has at hand, now and at the time of the event. Other variables at influence include the duration and severity of the trauma, what meaning (or lack of) was given to the traumatic event, as well as the kinds of supportive and reassuring presence provided (or not) by community, family or friendship network.

The more prolonged traumas are those that intrude into life so that the trauma itself becomes a limiting descriptor of identity. Post Traumatic Stress Disorder (PTSD) is the psychiatric diagnostic category that captures within its definition a range of prolonged traumatic response (over 1 month). The category of Acute Stress Response applies to acute responses of less than 1 month. The American Psychiatric Association’s diagnostic manual (DSM IV) lists specific behavioral and experiential criteria for this condition. Included, in summary:

The individual has been exposed to event(s) where they have experienced,witnessed or confronted an event where actual or threatened death, serious injuryor threat to the integrity of the self was involved. The response to this can include fear, helplessness, terror.
The traumatic event is reexperienced by recurrent and intrusive mental images andfeelings (thoughts, dreams, nightmares, illusions, hallucinations, flashbacks, vivid recalls).
Psychological and somatic distress and reactivity to cues that symbolize or resemble aspects of the traumatic event.
Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (avoiding certain thoughts, feelings, conversations).
Restricted range of feelings, diminished interest in usual activities or association with people or places associated with the event.
Persistent symptoms of arousal such as difficulty falling or staying asleep, anger outbursts, hypervigilance, exaggerated startle response, difficulty concentrating.

Theorists on trauma (van der Kolk, Herman) have looked beyond these symptom and behavioral descriptions to a deeper level of human experience with the fully dimensional ways in which people respond to and reexperience trauma. The term Complex PTSD has been coined to capture how personality, views of self and other and perception itself is shaped and altered by trauma. Complex PTSD can include:

Alterations in regulation of affect and impulses, such as difficulty in managing feelings, self destructive urges or engaging in risk taking or dangerous behavior.
Alterations in attention or consciousness, such as dissociation, selective memory loss and time distortion for discrete periods of the traumatic event.
Somatic complaints such as chronic pain, digestive problems, cardiopulmonary symptoms, sexual problems.
Alterations in self-perception such as an individual’s beliefs that they’re permanently damaged; shame and aloneness in the sense that no one could understand are prominently felt.
Alterations in the perception of the perpetrator such as preoccupations with hurting the perpetrator, idealizing them, or holding very distorted views about them. Thoughts may minimize or rationalize the event.
Alterations in relation with others such as difficulty trusting, victimizing others (do as has been done to) or reenactment of trauma from the past in overt or covert ways.
Alterations in meaning of life, of previously held sustaining beliefs. Despair, hopelessness, or emptiness may be accompanying feeling states, or generally feeling ineffective in one’s life.

Trauma is resolved by working with all of the resources one has at hand now, in present time. Resources are everywhere: they can be internal or external, they can include special people, a sense of solidity or presence in one’s own body, personal mastery, sustaining or nurturing beliefs, spirituality, financial stability, nature, art, color or ritual. Consideration of what effective resources are available is as necessary as reviewing what behaviors or personal stances keep the symptom picture intact, stuck or reenacted now.

Trauma held in its undigested state will remain active or, if left unattended, will settle into shape in personality structure in the form of traits, maladaptive behaviors, relational habits or attitudes. Traits can become habit, habits become ingrained, efforts are made to keep a steady state of coping and maintaining in place.

The work of resolution involves sequencing or working though traumatic events on all levels of experience:

bringing attention to and working with physical sensations stimulated by trauma or its reenactment (somatic).
working through self limiting beliefs about self, others and one’s place in the world (cognitive).
evaluating pharmaceutical interventions when needed (biochemical).
relearning effective regulation and flow of feeling states; working through highly charged responses gripped in memory (emotion).
re-regulating arousal patterns and information processing systems (neurological).
repairing and forming — maybe for the first time — supportive, loving, responsive social lives; forming effective and flexible boundaries with others (relational).
establishing a new order of connection with something bigger than ourselves, be that nature, a greater realm of mind or God (spiritual).